Where have all the spermatozoa’s gone?
Male infertility accounts for approximately 40% of infertility cases.
To be considered fertile, males need to deposit a minimum of 40 million sperm into the vagina to ensure a single sperm encounters an egg. The current standards (WHO) for male fertility are based on four criteria
• Volume : more than 1 milliliter
• Count : more than 20 million sperm per milliliter
• Motility : more than 50% moving vigorously
• Morphology : more than 14% normal forms (no deformities of head, tail etc).
Sperm are manufactured in the gonads, and sperm production is very sensitive to variations in temperature (decreasing with higher temperatures, as in tight pants) and to the chemicals and pollutants from the environment. Sperm formation takes around 48 days in the gonads, before final maturation for 2 or more weeks in the epididymis.
The long developmental time of sperm means that events in a mans life, such as fever or an episode of high testicular temperature, can have adverse effects on the quality of sperm being ejaculated over 2 months later.
Over the last several decades the “standards” for sperm quality and quantity, as described above, have been revised downwards. Normal parameters of 20 years ago described sperm counts double the current standard, and with a much higher percentage of normal forms. The standards for deposits into sperm banks have been progressively lowered because too many donors were being rejected2.
Where have the sperm gone?
The average sperm count has dropped by 45% – from 113 million per milliliter in 1940 to 66 million per milliliter in 1990. Semen volumes have also dropped, while the number of men with low sperm counts (less than 20 million per milliliter) has tripled from 6 to 18%. The more recently a man was born, the lower the average sperm count and the greater the percentage of abnormalities. Such a trend means that a 30 year old man in 2006 might have a sperm count of 32 million per milliliter, about 25% the count of the average man born in 1925.
There are several reasons put forward to explain this precipitous decrease. The most compelling etiology appears to be increased exposure to environmental pollutants either during gestation or later in life. Substances that are especially deleterious include polychlorinated biphenols (PCB’s, used in the manufacture of plastics), dioxin and pesticides such as DDT. Also implicated are the various chemical and solvents used in the manufacture of adhesives, inks, dyes and paint. There are studies showing that men who handle the various chemically noted have impaired fertility3. Many of these chemicals, and other substances used in agriculture and manufacturing, act like estrogens or anti-androgens. While normal plant estrogens can be metabolized or excreted, these artificial compounds that act like estrogens resist normal breakdown and accumulate in the body.
In addition, recreational drugs such as alcohol, tobacco and cannabis have significantly negative effects. It has been shown that smokers have an average of 13-17% lower sperm counts than non-smokers. Stopping smoking is often followed by significant improvement in sperm counts some months later.
Prescription drugs can cause problems as well, notable examples including salazopyrine used to treat ulcerative colitis, and phenytoin used to treat epilepsy. Some chemotherapy and anti hypertension drugs can also lower sperm counts4.
Until fairly recently, it was thought that age was irrelevant to sperm quality, indeed many older men (Rupert Murdoch being a notable and current example) father small children well into their seven and eight decades. More recent research5, however, has shown the probability of impregnation decreases with older men. Men it seems, also have a biological clock that runs down as they age (not as urgently as women). In Chinese medical terms, the connection to the kidney and the gradual decline of jing (essence) is clear.
Male infertility and Chinese medicine
In Chinese medicine male infertility is based in the kidneys. The sperm constitutes about 1% of the volume of ejaculate, the remainder made up of nourishing elements crucial to the sperms survival. The dynamic sperm represent the yang within moistening and nourishing yin of the semen. Both the yin and yang aspects, the sperm and the fluid containing them, must be considered in treatment.
The basic requirement for full reproductive potential is strong kidney jing and a normal balance of kidney yin and yang.
Most cases of male infertility will be diagnosed as either kidney yin or kidney yang vacuity, or a mixture of both. There may be complicating factors depending on whether there is local pathology of the testicles. Damp heat in the case of an acute, sub acute or chronic infection; Blood stasis when there is mechanical blockage from trauma, scarring, stenosis, etc.
The TCM patterns are;
• Kidney yin vacuity
• Kidney yang vacuity
• Damp heat
• Blood stasis
Kidney yin vacuity
The heat generated by insufficient yin is the main cause of sperm problems in the yin vacuous male. The slightly elevated temperature inhibits the sperm producing cells, while the decrease and drying of fluids means the quality, quantity and viscosity of seminal fluid is compromised. These men are often high achievers, driven in their careers and working long hours with a hectic lifestyle. They may exhibit some of the typical yin vacuity symptoms such as restlessness, insomnia, heat at night, a thin wiry body and a dry red tongue, although in relatively young or otherwise relatively healthy men these signs may be absent.
Libido is often high, but performance and staying power poor. Premature ejaculation can be a feature.
The sperm test will often reveal a high percentage of abnormal forms, increased ejaculate viscosity and poor liquefaction.
Kidney yang vacuity
Yang vacuity leads to a failure of all aspects of reproduction; libido, manufacture of sperm, sperm performance and the ability to get and maintain an erection sufficient for impregnation. Yang vacuity tends to be more common in older males, while yin vacuity is often found in younger men with stressful and hectic lifestyles.
The features may include cold intolerance, lethargy, impotence, low libido, a pale swollen tongue, nocturia and lower back ache.
The sperm tests reveals low sperm count and poor motility.
Treatment of Kidney vacuity
Because sperm takes a long time to complete the growth and maturation cycle (2-3 months), treatment should persist at least this long and ideally for six months. In addition to the Chinese medical herb strategies outlined below, a common sense approach to diet and lifestyle is essential for satisfactory results. Regardless of the Chinese medical pattern being treated, the sperm profiles of all men will benefit from cessation of smoking, moderation of drinking habits, a healthy vegetable rich diet free from artificial additives, preservatives etc., and avoidance of unnecessary pharmaceutical and known sperm inhibitors.
The Chinese medical treatment must take both yin and yang aspects into account, as growth of yang depends on a solid base of yin, while yin requires the transformative power of yang to build and regenerate.
Where there is a tendency towards yin or yang vacuity, treatment will be skewed in that direction, while always paying attention to the other.
There are a number of formulae that have a general yin or yang supplementing affect, which in themselves will improve sperm quality. The formula selected can be enhanced however, by other herbs with a known and specific action on the sperm. When using teapills, mixing and matching several formulae depending on the mix of pathology works quite well. The same formulae can be made up in concentrated powders, but I find the teapills do the job just as well when taken consistently for the full treatment duration. In addition, building of Kidney yin, yang or jing is a slow incremental process which cannot be forced. Small regular doses of medicine over some months is the way to reliably build Kidney energy. Teapills are ideal for this purpose. Similarly, compliance is an important consideration in lengthy treatments such as this, especially for busy men, and the most convenient delivery method is usually the one that produces the best results.
To supplement kidney yin, the base formula is LIU WEI DI HUANG WAN (Six Flavour Teapills). This is the formula from which all Kidney supplements are derived. If there is clear signs of heat, the more cooling ZHI BAI BA WEI WAN (Eight Flavoured Rehmannia Teapills) can serve as a base. Another excellent starting formula is the more enriching ZOU GUI WAN (Left Side Replenishing Teapills).
To either of these suitable base formulae, herbs specific to sperm production and quality can be added.
He shou wu (Polygoni multiflori Radix) has a specific effect on increasing the quantity of sperm (SHOU WU PIAN).
WU ZI YAN ZHONG WAN (Five Ancestors Teapills) can be added to specifically augment the underlying jing, and therefore improve sperm quality, in particular when there are high proportions of abnormal forms. This formula has been the subject of research that has shown it has a significant action on increasing the antioxidant enzyme superoxide dismutase (SOD) which mops up free radicals preventing oxidative damage to the developing sperm, as well as increasing testosterone levels6.
By acting at the level of the jing, this formula is suitable to be added to both yin and yang supplementing strategies.
If qi is weak, add SHEN QI DA BU WAN.
When there is a relatively equal balance of Kidney yin and yang vacuity, or no clear indication one way or the other, a formula that addresses both aspects equally can be employed. HUAN SHAO DAN (Return to Spring Teapills) is such a formula incorporating aspects of yin and yang supplementation and the fundamental aspects of WU ZI YAN ZHONG WAN as well.
When yang vacuity is clear and primary, the base formula of choice is FU GUI BA WEI WAN (Golden Book Teapills) or YOU GUI WAN (Right Sided Replenishing Teapills) augmented with He shou wu and WU ZI YAN ZHONG WAN. Yang vacuity is also benefited by the addition of deer horn for added warmth and jing support.
Because yang vacuity is often characterized by poor erectile function, herbs to quicken the blood and increase circulation to the genitals can improve function significantly7. The simple addition of San Qi (Panax notoginseng Radix), SAN QI PILLS or DAN SHEN WAN (Salvic Teapills) do the job admirably.
The diagnosis of Damp Heat usually implies some sort of infection in the reproductive system. As a cause of male infertility it is not so common in developed countries due to the availability of antibiotics, however, low grade, sub-acute or poorly treated cases are sometimes seen.
Damp Heat can complicate Kidney vacuity because the vacuity makes the reproductive system more vulnerable to pathogenic invasion. When Damp Heat complicates Kidney vacuity it should be treated first until the Damp Heat has been cleared. Unlike the Kidney vacuity patterns, the treatment of Damp Heat can more vigorous, utilizing larger doses of herbs in either concentrated powder extract or decoction.
The main featured are discharge from the penis, itching in the genital area (inflammation, boils, redness, jock itch etc), painful urination, fullness pain in the scrotum or perineum and yellow tongue coat at the root. The Damp Heat may be localized in the lower jiao or may affect the Liver organ system or channel pathway.
Sperm tests will reveal poor motility, poor liquefaction or hyperviscosity.
When the liver is involved, there will often be perpetuating factors such as alcohol and diet. Liver specific signs may be present- red sore eyes, headaches, short temper etc.
When Damp Heat is localized in the lower jiao, either BI XIE SHENG SHI WAN (Subdue the Dampness Teapills – with more heat) or BI XIE FEN QING WAN (Bi Xie Fen Qing Teapills – with more damp) may be used. Depending on the degree of Damp Heat and the delivery method selected, several months of treatment may be required to completely clear it before commencing Kidney supplementation.
With the involvement of the Liver, LONG DAN XIE GAN WAN (Snake and Dragon Teapills) is employed alongside appropriate alterations in lifestyle and habit.
Blood (and qi) stasis type male infertility reflects those conditions that obstruct the passage of sperm, such as vascular abnormalities, scarring from trauma, as well as surgery, vasectomy reversal, varicocele repair etc.). Chronic Damp Heat can lead to Blood stasis by damaging the epididymis and other tubules through the inflammation (and stenosis) Damp Heat may produce.
When Blood stasis is primary, there may be Blood stasis specific signs such as focal pain in the testicles or distended purple vessels visible in the scrotum. These signs, however, are often absent, and the medical, surgical or traumatic history will be significant.
Sperm tests may reveal anti-sperm anti-bodies (in the case of vasectomy reversal) and high levels of sperm (in the absence of significant complicating yang vacuity).
In relatively mild cases it may be sufficient to simply add a Blood quickening herb such as San Qi (Panax notoginseng Radix) or Dan Shen (Salvia miltiorrhiza Radix) to an appropriate Kidney supplementing formula. When more primary and thus requiring resolution before any other treatment can commence, a formula such as XUE FU ZHU YU WAN (Stasis in the Mansion of Blood Teapills) may be used for a few months to activate local qi and Blood stagnation.
In uncomplicated cases of qi and Blood stagnation such as varicoceles, surgery is usually the fastest and most effective treatment, followed up by Blood moving herbs to prevent excessive scarring.
Clinical outcomes and objective sperm test results clearly show that, in many if not most cases of male infertility (the exceptions being situation such as a total absence of sperm or sperm producing cells), the quality and quantity of sperm and semen can be reliably improved by persistent use of Chinese medicine in combination with appropriate lifestyle changes. Whether this results in pregnancy or not depends on other factors beyond our control. Regardless of whether or not pregnancy occurs, treatment will improve the general health of the individual concerned, and maximize the constitutional potential (via jing) of any child that may be conceived in the future.
Much of the material in this article is from the marvelous “Treatment of Infertility with Chinese Medicine’ by Jane Lyttleton (2004) Churchill Livingstone, Edinburgh
1. Jansen RPS 1997 Getting Pregnant. Allen and Unwin, Sydney
2. Lyttleton, J 2004 Treatment of Infertility with Chinese Medicine. Churchill Livingstone, Edinburgh
3. Savitz DA, Whelan EA, Kleckner RC 1989 Effects of parents’ occupational exposures on risk of stillbirth, preterm delivery and small for gestational age infants. American Journal of Epidemiology 129 (6):1201-1218
4. Lyttleton, J 2004 Treatment of Infertility with Chinese Medicine. Churchill Livingstone, Edinburgh
5. Ford WLC et al 2000 Increasing paternal age is associated with delayed conception in a large population of fertile couples: evidence for declining fecundity in older men. Human Reproduction 15(8):1703-1708
6. Xie Zhu-Fan 1995 Best of Traditional Chinese Medicine. New World Press, Beijing
7. Guo Jun et al 1999 A parallel study of the effects in treatment of impotence by tonifying the Kidney with and without improving Blood circulation. Journal of Traditional Chinese Medicine 19(2):123-125